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Journal Reading030225 - Prehospital time (1).pptx
- 1. JOURNAL READING Prehospital timeand mortality in polytrauma patients: a retrospective analysis Nadira Maharani Pembimbing: dr. Imamul Aziz Albar, SpOT(K)
- 3. Abstract ● The timefrom injury to treatment is considered as one o the major determinants for patient outcome after trauma. ● Not much outcome data available yet for the severely injured ● Study aim: investigate association between prehospital time and mortality in a Dutch level I trauma center Background ● Retrospective study using Dutch trauma registry over a 2-year period. ● Subject: Severely injured polytrauma patients (ISS 16) ≥ ● Outcome: in hospital mortality ● Variables: Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS Methods
- 4. Abstract ● 342 polytrraumapatients ● The total mortality rate was 25.7% (n = 88) ● Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) (p = 0.819) ● The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156). Results ● This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality Conclusion
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- 6. BACKGROUND – Summary ●Prompt medical assessment, onsite treatment and transport is critical to optimize survival rates ● Aim of Emergency Medical Service: stabilize severely injured patients and rapidly transport them into appropriate trauma center. ● Optimal duration of prehospital time for severely injured patients is difficult to determine ● This retrospective single center analysis aimed to examine association between prehospital time and mortality in polytrauma patient in Dutch level I trauma patients
- 7. Background: Importance Improvement ofEmergency Medical Services (EMS) care (Prehospital) in resuscitation and rapid transportation might be of substantial impact on survival rates. Little empirical data exists considering severely injured patients in a prehospital setting ● Aim: Investigate association between prehospital time and mortality in a Dutch level I trauma center ● Hypothesis: Short pre- hospital times reduce mortality rates and improve poly- trauma patients’ outcome
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- 9. ● Type: RetrospectiveSingle Center Study ● Data: Data derived from Dutch trauma registry of the National Network of Acute Care. ● Setting: Level-1 Trauma Center, Amsterdam UMC, Location VUmc ● Period: 2-year period (exact year were not mentioned in methods) METHODS
- 10. METHODS ● Population: Adultpolytrauma patients (ISS 16) ≥ ● Inclusion Criteria: Treatment on-scene by EMS or both EMS and HEMS, followed by a direct transport to the trauma center ● Exclusion Criteria: Age <18, missing data, missing prehospital times, secondarily referred from other hospital Participants ● Characteristics: Patient characteristics, comorbidity (ASA); mechanism of injury, type of injury, HEMS assistance. ● Scoring: ISS Score, preHospital GCS ● Total prehospital time: From EMS dispatch center received initial call about the incident until arrival at the trauma center ● Outcomes: ● In-Hospital mortality Parameters
- 11. METHODS – Interventionsand Treatments ● EMS dispatch center receive initial call from layperson/ upon request ● HEMS can be dispatched, upon request from EMS ● After on-scene assistance, patient is transported to the nearest trauma center ● In this study: catchment area in Amsterdam UMC, location VUmc Prehospital care provided
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- 13. Study Population Characteristics StudyPopulation (n=342) ● Predominantly male patients with mean age 52.1 (SD 20.5) ● 94.2% caused by blunt trauma (MVA) ● Median ISS of 22 ● Total Mortality Rate: 25.7% (n=88) ● Overall mean hospital time: 45.2 min ○ Surviving: 45.3 ○ Non-surviving 44.9 ○ P 0.819 ● Significant difference in prehospital GCS (P<0.001) and ISS (P<0.001)
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- 15. Mortality Analysis ● Unadjustedassociation between prehospital time and mortality is non linear ● No evidence of association (p: 0.754) ● Confounder adjusted analysis also showed no association between prehospital time and mortality (p:0.156)
- 16. Mortality Analysis ● Significantassociation with mortality were observed for age, comorbidity, prehospital GCS and ISS (all p <0.001) ● AUROC 0.872
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- 18. Summary of KeyFindings Association to Mortality: • No Association between prehospital time and mortality was found. • Mean prehospital time in this study shorter than to studies conducted in other trauma system • Consistent with literature, increased age, comorbidity, low prehospital GCS, amd high ISS showed significant association with mortality Challenging Views • Some studies suggest prehospital time seems beneficial, others-including this study, did not observe an association between prehospital time and mortality. Even in severe polytrauma patients.
- 19. Discussion Study Recommendation • Avoiding unnecessarydelays in transporting patients is still a prudent recommendation. Relevance to Practice • Highly-trained and specialized EMS teams performing stabilization on-scene potentially live-saving • Shorter time to advanced treatment might explain why prehospital time is not necessarily related to worse outcome
- 20. Limitations of theStudy • Retrospective nature of study have confounding and missing data. This might lead to selection bias • Single center study Specific characteristics of study prehospital operation: short distance to trauma center, availability of HEMS → not readily generalize to settings with other logistic and geographic characteristics
- 21. Future Research and Implications ●Include individual patients that may benefit short prehospital time ● Explore additional factors especially focusing on physiologic parameters in the severely injured actors ● Individual patients may still benefit from short prehospital time
- 22. Question In this paper YesNo Unclear N/A Were the two groups similar and recruited from the same population? V Were the exposures measured similarly to assign people to both exposed and unexposed groups? V Was the exposure measured in a valid and reliable way? V Were confounding factors identified? V Were strategies to deal with confounding factors stated? V Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? V Were the outcomes measured in a valid and reliable way? V CRITICAL APPRAISAL
- 23. Question In this paper YesNo Unclear N/A Was the follow-up time reported and sufficient to be long enough for outcomes to occur? V Was follow-up complete, and if not, were the reasons to loss to follow-up described and explored? V Were strategies to address incomplete follow-up utilized? V Was appropriate statistical analysis used? V CRITICAL APPRAISAL
- 24. Conclusions This retrospective analysisbased on polytrauma patients from a level I trauma center found no association between prehospital time and mortality. Data do not exclude that individual patients may benefit from short prehospital times, and we suggest avoiding unnecessary delays in transporting patients to an appro- priate trauma center.
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Editor's Notes
- #3 Abstract Background: The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center. Methods: A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality. Results: In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156). Conclusion: This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.
- #4 Abstract Background: The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center. Methods: A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality. Results: In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156). Conclusion: This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.
- #10 In the Netherlands, additional to the care provided by EMS, assistance from physician staffed Helicopter Emergency Medical Services (HEMS) can be requested to provide advanced specialized care and interventions on- scene, such as tracheal intubation, administration of ad- vanced analgesia, chest tube placement and surgical pro- cedures
- #11 A HEMS crew consisting of a HEMS phys- ician (trauma surgeon or anesthesiologist), HEMS nurse (Emergency Department’s or EMS nurse), HEMS pilot, and chauffeur can assist the EMS crew providing ad- vanced lifesaving care on-scene.
- #22 1. Were the two groups similar and recruited from the same population? Yes, the study participants were recruited from the same population, as all 59 residents were first-year Emergency Medicine (EM) trainees at Grady Memorial Hospital, a Level I trauma center. They were part of the graduating classes of 2021, 2022, and 2023. All residents attended a standardized ultrasound "bootcamp" during the first month of their residency, receiving similar foundational training in ultrasound, including FAST exam techniques. Since the study did not explicitly compare two separate groups (e.g., intervention vs. control), the participants were treated as a single cohort for analysis. Comparisons, such as the number of exams required for competency, were made within the cohort (e.g., performance by training year). Therefore, all residents had comparable training and conditions for skill acquisition, ensuring homogeneity in the study sample. 2. Were the exposures measured similarly to assign people to both exposed and unexposed groups? As there were no distinct groups being compared based on exposure status, this question may not directly apply. However, the study's methodology ensured uniformity in exposure (training and feedback) and measurement of outcomes across all participants. 3. Was th exposure measured in a valid and reliable way? Yes, the exposure (the number of FAST exams performed by residents) was measured in a valid and reliable way. 4. Were confounding factors identified? The study noted that residents performed various point-of-care ultrasound (POCUS) exams throughout their training, which could influence their overall ultrasound competency, including FAST exam performance. 5. Were strategies to deal with confounding factors stated? All residents participated in a standardized "bootcamp" at the start of their training, covering basic ultrasound physics and hands-on POCUS training, including FAST exams. The Task-Specific Checklist (TSC), a validated and objective scoring tool, was used to assess the quality of FAST exams uniformly for all residents. 6. Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? At the beginning of their training, all participants were first-year Emergency Medicine (EM) residents who had not yet undergone significant clinical exposure to FAST exams. 7. Were the outcomes measured in a valid and reliable way? The Task-Specific Checklist (TSC) was used to measure competency. This tool is a validated, evidence-based method specifically designed for assessing the quality and proficiency of FAST exams. A competency threshold (score ≥18) was established based on prior research, aligning the measurement with known predictors of expertise.
- #23 8. Was the follow-up time reported and sufficient to be long enough for outcomes to occur? The study evaluated FAST exam performance by Emergency Medicine (EM) residents over a four-year period (July 2018 to June 2022), covering residents from the classes of 2021, 2022, and 2023. Given that residents perform multiple FAST exams during their first year, the follow-up time was adequate to capture the progression to competency for all participants. 9. Was follow-up complete, and if not, were the reasons to loss to follow-up described and explored? The study included all FAST exams performed by 59 first-year Emergency Medicine (EM) residents during their initial year of training, as documented in the Telexy Qpath system. This ensured that every exam was recorded and assessed. The study does not report any participants dropping out or failing to complete the required FAST exams. 10. Were strategies to address incomplete follow-up utilized? The use of the Telexy Qpath system ensured that all FAST exams performed by residents were automatically archived. This significantly reduced the risk of incomplete data or missed exams. All participants were part of a structured Emergency Medicine residency program with mandatory ultrasound training. This environment likely ensured consistent participation and reduced the possibility of residents not completing the study. 11. Was appropriate statistical analysis used? The use of descriptive statistics was appropriate for addressing the primary research question: determining the number of FAST exams required for competency.